1002 Outcomes and Documentation of Minor Skin Surgery at a General Practice
A Dawidziuk, D Turner, E Lakasing- Surgery
Abstract
Aim
This audit aimed to evaluate outcomes and documentation of minor skin surgery at a general practice. The basis of the audit was the National Health Service Directed Enhanced Service Specification for Minor Surgery 2021-22 (Minor Surgery DES SLA 2021/22).
Method
The scope included all minor surgery procedures coded as incisions and excisions on the EMIS electronic patient records system carried out at the practice between 25th January 2021 and 25th January 2022. All included records were evaluated for documentation of written consent, comprehensive surgery note, complications, all excised material sent for history, histology results recorded, malignancy reported on histology, and accordance of clinical and pathological diagnoses. The audit standard was set at 80% by consensus of senior clinicians.
Results
The initial search yielded 104 patient records. Following deduplication, 100 cases were included in the audit (8 incisions, 92 excisions). 86% had signed written consent and comprehensive note uploaded to the electronic patient records system (86/100). Complications, including infection, were recorded in 10% of cases (10/100). 92% of cases had all excised material sent for histology and results recorded on the electronic system (85/92) with some material sent in 100% of excisions (92/92). No malignancy has been reported on histology results. The accordance of clinical and pathological diagnoses was confirmed in 79% of excisions (73/92).
Conclusions
Minor skin procedures completed in the evaluated period met the audit standards. Minor surgery documentation could be further improved by introducing a dedicated electronic note template.